INFORMATION

Vaginal prolapse

Women having vaginal prolapse can experience backache and a dragging sensation in the vagina, and as the condition worsens, may notice a vaginal lump, difficulty voiding, bladder incontinence and difficulty emptying the bowel. It is a common problem that can affect one’s quality of life.

There are three main types of vaginal prolapse in accordance to the anatomical structure involved. The bladder sits in front of the vagina; the uterus, cervix and small bowel at the top end of the vagina; and the large bowel at the back of the vagina. There are tough fibrous tissues called fascia which surround the front and back wall of the vagina, and fibrous bands which support the cervix like a suspension cable to the pelvic bone. Disruption / damage to these supporting fibrous tissues form the basis of prolapse development.

Damage to the front / anterior fascia will cause the bladder to prolapse (also called cystocoele). See diagram A

Damage to the back / posterior fascia leads to prolapse of the back passage (rectocoele, see diagram B) and of the small bowel (enterocoele, see diagram B);

Damage or overstretching of the cervical suspensory fibrous tissue would cause the uterus and cervix to drop and prolapse (uterine procidential).

Any factors that weaken or damage these fibrous tissues can cause vaginal prolapse. Some of the known factors are childbirth (especially following a traumatic vaginal delivery), menopause, obesity, chronic coughing, chronic constipation, occupational lifting and family history of prolapse. the uterus, cervix and small bowel at the top end of the vagina; and the large bowel at the back of the vagina. There are tough fibrous tissues called fascia which surround the front and back wall of the vagina, and fibrous bands which support the cervix like a suspension cable to the pelvic bone. Disruption / damage to these supporting fibrous tissues form the basis of prolapse development. Damage to the front / anterior fascia will cause the bladder to prolapse (also called cystocoele); damage to the back / posterior fascia leads to prolapse of the back passage (rectocoele) and of the small bowel (enterocoele); while overstretching of the cervical suspensory fibrous tissue would cause the uterus and cervix to drop and prolapse (uterine procidential).

Management of prolapse requires a dedicated long term approach which includes:

Whilst preventive measures can help slow down the progression of the prolapse, more often than not, women with symptomatic and visually apparent prolapse would need surgical intervention for long term reversal of the problem. Vaginal pessary can provide certain degree of support but would still need some pelvic floor muscle strength to keep the pessary in place. Women having pessary also requires regularly 6-12 months review due to the risk of vaginal wall erosion and the need for larger size as the vaginal wall stretches.

There are different types of vaginal prolapse surgery. The most popular type is the vaginal prolapse repair using native tissues. The surgery is performed under general anaesthesia, and the prolapse is surgically reduced using strong but dissolvable sutures to repair the torn fascia. The top of the vagina can be sutured to the surrounding ligaments, and one of these types is called the sacrospinous colpopexy. Other surgical methods described are hysterectomy, uterosacral colpopexy, sacral colpopexy, use of various types of vaginal mesh, and colpocleisis. Your specialist should recommend the most suitable surgical technique and explain how it works.

Surgery is not performed without any risks. Short term complications are bleeding, infection, deep vein thrombosis and pain, but most are well managed during your post-operative care. Long term pain, especially painful intercourse, is not common but tends to occur in women who had mesh augmentation. Bladder incontinence can also occur but it is usually related to the prolapse repair surgery unmasking an underlying weak bladder which is often associated with a bladder prolapse. Recurrence of prolapse has been reported to occur in up to 30% of cases which highlight the importance of long-term management involving lifestyle modification, oestrogen support and regular pelvic floor exercises.

Are you wondering about having your own baby?

Having a baby is one of our greatest milestones in life – it is a wonderful experience to be able to give birth to our children and raise a family. There are many books and reading materials out there on pregnancy, but our specialist will help you focus on what is important and relevant to you.

Here, we take a holistic approach to understand your needs, to demystify myths surrounding fertility, pregnancy and childbirth, and to manage problems which can affect your chances of having a healthy baby. Getting a pre-pregnancy counselling allows you to address all your concerns with our specialist who will listen to your queries, systematically assess your health and give you a comprehensive yet easy-to-follow roadmap. This process will start with a comprehensive history taking, an appropriate examination, and a set of blood tests and ultrasound scan. You will then receive counselling about your health status and ways you can do to enhance your health and your chances of having a spontaneous pregnancy. This would give you better preparation and greater confidence in going to the next stage of your journey to having a baby.

One pertinent point to note, don’t wait too long to start a family – get a fertility check-up which includes an assessment of your ovarian reserve to help you work out how much time left in your reproductive lifespan before it is too late. We can discuss the option of storing your valuable eggs or embryos if you wish to delay your childbearing plan.

Do you wish to have a baby in style?

Having a baby is a very personal journey. Some find it easy and straight-forward, others have a tougher and more risky journey. Whichever journey you go through, it is a personal one, which makes it sweeter if you have someone supporting you through, and have a specialist guiding you all the way to experience the best moment of your life – the birth of your precious baby. You may have read or hear stories about the things that could go wrong in pregnancy and childbirth, and may be constantly worrying about labour pain and how on earth the baby can come out.

Yeap, those worries are legitimate because pregnancy and childbirth can be risky and potentially life-threatening to mother and/or baby, and these complications can happen even in young, healthy and supposedly low risk pregnant women. Looking back at history, it was not too long ago that our grandparents and the generations before them dreaded about the moment of not seeing their wife and baby survive through the childbirth process, and now these events are very uncommon, thanks to modern surveillance of pregnancy progress and childbirth in the labour ward with modern facilities like operating theatre, blood-bank, and nursery to provide emergency backup in case of any unexpected complications.

Our mission is to ensure you have a memorable pregnancy and childbirth experience; to support and guide you and your partner throughout this very personal journey; and above all, to make this process safe and comfortable.

In our clinic, you will see the same specialist throughout your pregnancy care, who is almost certain will be there delivering your baby. Your pregnancy care will include a comprehensive assessment and a personalised pregnancy care plan. With each subsequent antenatal visit, our specialist will monitor your health; the growth and well-being of your baby with an ultrasound scan to check your baby’s position, heartbeat, growth and fluid in the womb; and address any concerns along the way. You will be encouraged to attend antenatal classes organised by the private hospital you intend to have your confinement. The choice of delivery and pain management will be discussed to select the one you prefer, and although we would normally promote natural birth, how you wish to have a baby is entirely your choosing as long as it is deemed safe and reasonable. This would mean no homebirth or water-birth, and we would reason out with you why those choices pose a potential risk to you and the people looking after you.

We also put a strong focus on good pain management as we understand that labour can be painful and women can have varying degree of pain tolerance. Good pain management ensures you have control over your birthing experience, and help you avoid traumatic childbirth.

Our overriding goal is to provide you and your partner a comprehensive first-class professional care throughout your pregnancy journey til you have your baby in your arms, and to not only ensure a safe outcome but also bring you a memorable and wonderful experience. We call this, having your baby in extraordinary style.

Family Planning

Family planning is basically a strategy to influence the number of children one wishes to have and when. Although it is often not a precise method, it allows people to choose and to manage their family size and structure, and this is often a very personal choice influenced by one’s background, faith and society. There are many different methods to choose from and basically can be categorised into 5 groups: natural methods, barrier methods, contraceptive pills, non-pill alternatives, and sterilisation.

There is no right decision, just one which suits your needs and is compatible with your belief and values. It is also something that can change over time, and as such, it is important to choose methods which give you the flexibility to change your plan as your circumstances evolve.

Menopause

Reaching menopause can be a life changing event for women as it indicates the end of reproductive age. The experience of going through menopause is highly individualised, from minimal symptoms to significant disruption to one’s daily living. It can be influenced by various bio-psycho-social factors like health condition, lifestyle, family history and cultural factors etc. Click Read More to find out more about menopause and its management.

What is menopause?

Menopause is a natural aging process that usually begins at 45-55 years of age, with an average age of onset in Australia at 51 years. Sometimes, it can be brought on by medical or surgical treatments. As we know, the ovary produces female hormones (oestrogen and progesterone) in a cyclical fashion to stimulate breast development and to regulate menstrual cycles through the growth and subsequent shedding of the womb lining (also called the endometrium). These hormones are actually produced by the maturing eggs, and hence, as the egg reserve becomes depleted with aging, so also the ovarian hormone production which starts to become erratic and eventually the levels become negligible. This explains why women approaching menopause often experience irregular periods which can also be heavy. This duration, which is also known as perimenopause or the transitional phase, can last for several years which can be a rather disturbing time of one’s life. Medically, a woman is diagnosed to be in menopause after she has gone for one full year without periods. From then onwards, the woman is considered to be in the postmenopause.

What are the symptoms?

Typical symptoms are irregular period, hot flushes and night sweats. Other common symptoms are headaches, mood swings, sleeping difficulty, general aches and pains, and tiredness.

Period change: Irregularity or any change of period probably is the first thing you will notice. You may skip periods or they may occur closer together. Your flow may be lighter or heavier than usual.

Hot flushes: A typical hot flush lasts a few minutes and causes flushing of your face, neck and chest. Some women become giddy, weak, or feel sick during a hot flush. Some women also develop a thumping heart sensation (palpitations) and feelings of anxiety during the episode. Hot flushes tend to start just before the menopause, and typically persist for 2-3 years.

Sweats: It commonly occurs when in bed at night. In some cases, they are so severe that sleep is disturbed and bedding and clothing need to be changed.

In the long run, there are some recognised associated changes affecting other parts of the woman’s body like dry skin and hair, dry vagina, breast changes, increased urinary frequency, weak bladder and accelerated bone calcium loss resulting in osteoporosis.

How is menopause diagnosed?

Menopause can be diagnosed when your period has stopped for a continuous 12 months and you are over the age of 45. If you are taking specialised medications to suppress your FSH production, your menopause can be medically induced until such time you come off the effect of the medications. And if you have both ovaries are removed surgically, your menopause will occur soon after.

For women reaching menopause before the age of 45, your doctor can organise a simple blood test (for FSH and oestradiol levels) to help confirm the diagnosis, and consider further tests to screen out other medical conditions like hypothyroidism, anaemia or depression which can mimic, or sometimes co-exist with, menopause.

How is menopause managed?

It is important to accept that menopause is a natural course of life and nothing to be embarrassed or worried about. Although nothing can be done to prevent menopause, unpleasant symptoms can often be reduced by maintaining a healthy lifestyle with a well-balanced diet and regular exercise; and having supportive friends and positive thinking. Some general tips you may wish to try are:

Choose a wide variety of fresh & healthy foods, ensure adequate fluids, and go for low-fat dairy foods with high calcium content, but try to limit alcohol intake (e.g. to no more than one standard drink per day).

Have regular exercise like walking at least 30–45 minutes on most days of the week.

Have some sunlight for natural vitamin D. Daily sun exposure is about 7 min during summer and 15min during winter but avoid the mid-day sun due to skin-damaging intense ultra-violet ray. Alternatively, you can take daily vitamin D tablet.

Quit smoking.

Treat vaginal dryness with lubricants such as K-Y Lubricant before vaginal penetration. Vaginal hormonal cream / pessary can be considered if over-the-counter treatments do not work.

Consider effective contraception for 12 months after the last period. Although the ovulation becomes irregular, there is a risk, albeit a very slim one, that you may fall pregnant during the transition period.

Be social and maintain a positive outlook.

Talk to your doctor about the option of going on hormone replacement (HRT) so that you can consider the benefits and purported risks associated with HRT. Studies have demonstrated that HRT is by far the most effective therapy for controlling menopause-related problems. Most importantly, management should be individualised as each woman's experience is different and unique. A proper counselling in this regard is very worthwhile.

What to prepare before going to your appointment?

Because there are a lot of things to discuss during consultation, it is a good idea to do some preparation before you go and see your doctor.

Keep track of your symptoms. For instance, make a list of what symptoms you have, how often you get hot flushes and how severe they are.

Make a list of any medications, herbs and vitamin supplements you are taking, including the doses and the frequency you take them.

Mar 2017: Vaginal Prolapse

Vaginal prolapse is very common in women, believed to be over 30% of the female population. Conservative treatment includes pelvic floor exercises, pessary support and vaginal oestrogen supplement (for postmenopausal women).

Surgical options can be divided into 2 main groups: 1) reconstructive, and 2) obliterative types. The former option is suitable for women who wish to retain vaginal sexual function.

For reconstructive surgery to be durable in preventing recurrent vaginal prolapse, the supportive fascia would have to be strengthened and reinforced, and this can be achieved by a combination of physiotherapy, oestrogen supplement, and native tissue repair using dissolvable sutures. Unfortunately, this approach still accounts for a recurrent rate of 10% to 70%.

To improve on our long term clinical outcome, several approaches have been introduced. Mesh was popularised in the 2000s and not long after, had been introduced worldwide as the panacea for vaginal prolapse.

In recent years, there have been quite a lot of bad publicity against the use of artificial meshes as more and more women reported unacceptable complications like dyspareunia and mesh erosion. Mesh erosion rate was reported as high as 25%.

Cochrane review recently reported a significantly higher rate of needing repeat surgery in women who had transvaginal mesh surgery compared to those who had native tissue repairs.

These complications resulted in some high profile lawsuit in the United States and review by the FDA.

Facing the threat of expensive lawsuits, many manufacturers of mesh began to withdraw their products from the market, e.g. Ethicon, AMS and Bard. AMS which became Astora in 2015 decided to settle more than 20,000 of its own cases for reportedly more than $2.4 billion.

Now, the only manufacturers left to provide transvaginal mesh in Australia is Boston Scientific and Restorelle. Studies on their mesh products are too limited to draw a conclusion on benefits & safety.

Our View & Approach:

We have always been sceptical of the use of transvaginal mesh because of the unique anatomy & function of vagina as opposed to abdominal hernias. So far, all our patients who needed vaginal prolapse repair did not end up having mesh put in.

Our approach to women needing prolapse repair is to have:

1) Good patient selection

2) Proper preoperative preparation

3) Careful anatomical repair

4) Long-term postoperative care

With patient selection, we offer vaginal reconstructive surgery in those whom we think have reasonable healthy native tissue. Those who have very weak tissue / fascia and are not sexually active are given the option for obliterative surgery, also called colpocleisis, which have a very low rate for recurrence and complications.

For those who wanted vaginal reconstructive surgery, every effort is made to strengthen their native tissue and maintain this long term. Our recurrence rate is comparatively low, with only two known cases in the last 5 years! As expected, there have been no reported failure rate for vaginal obliterative surgery in our cohort of patients.

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